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TCTAP C-011
Presenter
Khai Chih Teh
Authors
Khai Chih Teh1, Ahmad Khairuddin Mohamed Yusof1, Amin Ariff Nuruddin1
Affiliation
National Heart Institute, Malaysia1,
View Study Report
TCTAP C-011
CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS)
PCI To CTO ISR LAD In Acute Anterior Myocardial Infarction: Lifesaving Angioplasty For A Patient With Severe Triple Vessel Disease Unsuitable For CABG
Khai Chih Teh1, Ahmad Khairuddin Mohamed Yusof1, Amin Ariff Nuruddin1
National Heart Institute, Malaysia1,
Clinical Information
Patient initials or Identifier Number
MY177702
Relevant Clinical History and Physical Exam
A 57 year old man with history of triple vessel disease, PCI to LM- LAD and LCx in 2008, DM and HPT was planned for elective angioplasty for recurrent chest pain. Coronary angiogram in February 2020 showed complete ISR from ostium LAD, severe ISR from ostium LCx and severe mid RCA disease and he was deemed unsuitable for CABG. Physical examination was uneventful.On the day of coronary angiogram he developed severe chest pain and acutepulmonary edema. ECG showed ST elevation in V2 to V4.
Relevant Test Results Prior to Catheterization
ECHO: EF 53%, basalseptal hypokinesia, no valvular abnormalities PET - FDG scan: viable myocardium in all segments; EF 61% Creatinine 80, Troponin T 17 pg/ ml Coronary angiogram February 2020:Severe ISR with complete occlusion from ostium LADSevere ISR ostium LCx, severe disease OMSevere disease mid and distal RCA
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my feb1.avi my feb2.avi my feb3.aviRelevant Catheterization Findings
Coronary angiogram November 2020:
Severe ISR with complete occlusion of stent from ostium LADSevere ISR ostium to proximal LCx, severe disease OMSevere disease mid and distal RCA, retrograde to LAD via PD and PL to septal branches
my nov lad.avi
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Severe ISR with complete occlusion of stent from ostium LADSevere ISR ostium to proximal LCx, severe disease OMSevere disease mid and distal RCA, retrograde to LAD via PD and PL to septal branches
my nov lad.avi my nov lcx.avi my nov rca.aviInterventional Management
Procedural Step
We decided for PCI to CTO ISR LAD as there is high risk of further compromise to retrograde LAD circulation if attempts to PCI the LCx or RCA fails.Prior to beginning of procedure, the patient developed worsening acute pulmonary edema and required ventilator and inotropic support.
We used an Amplatz guiding catheter as an EBU 3.5 catheter provided poor support. The CTO ISR LAD was successfully crossed using GAIA I followed by GAIA II wire with microcatheter support. We exchanged the wire to a workhorse RUNTHROUGH FLOPPY wire.
We subsequently predilated the CTO ISR with RYUREI 1.0 x 5mm followed by SAPPHIRE II NC 2.0 x 12mm at high pressure. IVUS showed calcified ISR at the proximal LAD with MLA 1.90 mm2, distal stent size 2.25mm and proximal stent 3.25mm with extensive ISR throughout.
We proceeded with further preparation of the vessel with NC EMERGE 2.5 x 15 mm for the distal stent and SCOREFLEX NC 3.0 x 15mm at the proximal stent at high pressure. Repeat IVUS showed improved MLA at proximal LAD to 6.15 mm2 with good stent opposition. We then treated the prepared vessel with Drug Coated Balloon Sequent Please Neo 2.5 x 35 mm for the distal stent, and 3.25 x 35mm for the proximal stent up to ostium LAD into distal Left Main artery. Final results showed TIMI III flow with no complications.
Patient was successfully extubated within one day and recovered well with preserved LVEF 53% and no new wall motion abnormalities.
my gaiaII cross cto.avi
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We used an Amplatz guiding catheter as an EBU 3.5 catheter provided poor support. The CTO ISR LAD was successfully crossed using GAIA I followed by GAIA II wire with microcatheter support. We exchanged the wire to a workhorse RUNTHROUGH FLOPPY wire.
We subsequently predilated the CTO ISR with RYUREI 1.0 x 5mm followed by SAPPHIRE II NC 2.0 x 12mm at high pressure. IVUS showed calcified ISR at the proximal LAD with MLA 1.90 mm2, distal stent size 2.25mm and proximal stent 3.25mm with extensive ISR throughout.
We proceeded with further preparation of the vessel with NC EMERGE 2.5 x 15 mm for the distal stent and SCOREFLEX NC 3.0 x 15mm at the proximal stent at high pressure. Repeat IVUS showed improved MLA at proximal LAD to 6.15 mm2 with good stent opposition. We then treated the prepared vessel with Drug Coated Balloon Sequent Please Neo 2.5 x 35 mm for the distal stent, and 3.25 x 35mm for the proximal stent up to ostium LAD into distal Left Main artery. Final results showed TIMI III flow with no complications.
Patient was successfully extubated within one day and recovered well with preserved LVEF 53% and no new wall motion abnormalities.
my gaiaII cross cto.avi my post baloon.avi my final after DCB.aviCase Summary
This case illustrates the high morbidity and mortality risk in patients with severe 3 vessel disease who are not suitable for CABG. High risk PCI to the CTO LAD ISR in the setting of an acute anterior myocardial infarction successfully achieved good revascularization while reducing the risk of further compromise to retrograde circulation via the RCA and LCx, prevented further loss of viable myocardium, as well as achieving significant improvement of functional capacity and quality of life.